Parasomnias Treatment & Management

  • Author: David Bienenfeld, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK)   more...
 
Updated: Mar 29, 2012
 

Approach Considerations

Medical disorders, psychiatric disorders, and stress may precipitate or aggravate parasomnias. A careful history of psychosocial stresses, alcohol or drug use, and symptoms of depression should be obtained. Also, a detailed Mental Status Examination should be performed. Patients found to have an underlying psychological or psychiatric disorder should be seen by a psychologist or psychiatrist, and appropriate therapy should be offered.[44, 17, 3, 45, 46]

Pharmacologic treatment of parasomnias is aimed at lessening the frequency or intensity of the events. Whether any of the disorders respond better to one of the commonly used agents than to another remains unclear. Currently, no medications are available that are specifically indicated for these disorders; all medications used for these disorders are used off label.

For restless legs syndrome (RLS) and periodic limb movement disorder (PLMD), behavioral treatments (eg, relaxation therapy, biofeedback, and stress reduction) may be helpful, though they are not universally effective.

Surgical therapy is not indicated in the treatment of parasomnias.

Inpatient care is not indicated for parasomnias. If the patient is violent during these episodes, consider hospitalization. Should the patient need inpatient treatment for any other reason, outpatient medications should be continued unless contraindicated by the condition for which the patient is hospitalized.

Frequent contact and encouragement is critical for patients undergoing treatment for one of the parasomnias. When these disorders occur in children, parents must be encouraging and comforting.

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Pharmacologic Therapy

Rapid eye movement sleep behavior disorder

Treatment for rapid eye movement (REM) sleep behavior disorder is initiated with clonazepam 0.5-1.5 mg taken at bedtime. This medication has been shown to be beneficial in the long term. Drug discontinuance often results in prompt relapse. The exact mechanism of action of clonazepam in patients with REM behavior disorder is not known, but its serotonergic properties may inhibit nocturnal motor activity in the brainstem and thus prevent arousals.

Tricyclic antidepressants occasionally are used in the treatment of REM behavior disorder. Imipramine, which has serotonergic effects, has been used in the treatment of REM behavior disorder, but the effects are unpredictable. Anecdotal reports of the use of levodopa-carbidopa, gabapentin, and clonidine have been published, but the benefit of these drugs has not been systemically evaluated.

Restless legs syndrome and periodic limb movement disorder

RLS and PLMD are treated with 3 classes of medications.[47, 48, 49, 50, 51] Antiparkinsonian medications (eg, levodopa-carbidopa, bromocriptine, and pramipexole), have been used, as have benzodiazepines (eg, diazepam, clonazepam, temazepam, and lorazepam). Opiates (eg, codeine, oxycodone, methadone, and propoxyphene [now withdrawn from the US market]) have also been employed.

Several studies have reported efficacy of different medications belonging to these groups, but comparative studies between various classes of drugs or even individual drugs do not exist. Therefore, patients should receive a single agent, and, if no response is noted, they should be placed on another agent of the same or a different class. In more severe cases, a combination of drugs may be required. Some patients who do not respond to benzodiazepines alone, levodopa alone, or a combination of both may be treated with opiates.

Patients should receive the smallest possible dose and should be closely observed for the development of dependency. Accumulated experience dictates that the incidence of abuse, tolerance, or addiction to opiates or benzodiazepines in patients with severe RLS appears to be insignificant. The disabling condition of severe RLS must be treated aggressively.

RLS and PLMD are chronic conditions that require long-term pharmacologic therapy. Some patients may develop symptoms of restless legs during the daytime, and this may be treated with controlled release of levodopa-carbidopa administered in the evening and morning.

The effectiveness of levodopa (L-dopa) in the treatment of RLS has been confirmed by numerous studies. However, most patients on levodopa eventually develop a consequence called augmentation, in which when RLS symptoms appear earlier during the day and involve new parts of the body with increasing severity. Several studies have now confirmed that dopamine agonists can also be effective in RLS and PLMD while carrying a lesser risk of augmentation.

The American Academy of Sleep Medicine made the following recommendations for the treatment of RLS and PLMD with dopaminergic drugs[17] :

  • Levodopa with decarboxylase inhibitor and the dopaminergic agonists pergolide (withdrawn from the US market on March 29, 2007), pramipexole, and ropinirole are effective in the treatment of RLS and PLMD
  • Other dopamine agonists (talipexole, cabergoline, piribedil, and alpha-dihydroergocryptine) and the dopaminergic agents amantadine and selegiline may be effective in the treatment of RLS and PLMD, but the level of effectiveness of these medications is not currently established
  • No specific recommendations can be made regarding dopaminergic treatment of children or pregnant women with RLS or PLMD

Avoidance of certain drugs, such as tricyclic antidepressants, fluoxetine, or lithium, may be helpful because these generally worsen the symptoms of RLS and PLMD.

A decrease in body iron stores, as indicated by serum ferritin levels lower than 50 µg/L, should be corrected with iron supplementation. Oral iron is preferred but takes a long time because gastrointestinal absorption is low. However, replenishment is an effective treatment strategy for iron-deficiency anemia and may also relieve RLS and PLMD symptoms (if present). Oral repletion may be done with ferrous sulfate at a dosage of 640-960 mg/day in patients who have reduced iron stores.

An oral dose of 50-100 mg of levodopa in a controlled-release formulation is prescribed as initial therapy for RLS. For PLMD, a controlled-release preparation of levodopa combined with a decarboxylase inhibitor (carbidopa) at a dose of 50-100 mg is begun. A dose increase, not to exceed 200 mg, may be required to suppress RLS and PLMD completely. The major adverse effects of levodopa therapy are as follows:

  • Rebound of symptoms during the daytime
  • Tardive dyskinesia

For rebound symptoms during the daytime or for augmentation, patients can be treated with dopamine agonists (eg, pramipexole), anticonvulsants (eg, gabapentin or carbamazepine), or benzodiazepines (diazepam or lorazepam).[52] Tardive dyskinesia with use of levodopa is uncommon but may occur. The probable mechanism is denervation supersensitivity, which usually occurs in patients with Parkinson disease.

Dopamine agonists (eg, pramipexole) cause fewer problems than levodopa does and have become first-line drugs in the treatment of RLS and PLMD. In RLS patients refractory to therapy, opioids have been effective; however, such patients must be monitored for addictive behavior.

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Activity

In general, there is no reason to restrict or change the patient’s activity when a parasomnia has been diagnosed. However, the following precautions are valuable in the treatment of sleepwalking:

  • Remove potentially dangerous items
  • Locate the bedroom on the ground floor if possible
  • Lock the doors and windows
  • Cover glass windows with heavy drapes
  • Place an alarm or bell on the bedroom door
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Consultations

Consultation with a medical specialist or psychiatrist is indicated for the treatment of underlying conditions that may precipitate the symptoms of the parasomnias.

Consultation with a hypnotherapist may be of use for patients with sleep disorders. Hypnotherapy has been found to be a cost-effective and noninvasive treatment in adults with sleepwalking and sleep terrors.

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Contributor Information and Disclosures
Author

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Coauthor(s)

Ariz Anklesaria, DO  Resident Physician, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

Ariz Anklesaria, DO is a member of the following medical societies: American Medical Association and American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of Health Sciences: Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

Additional Contributors

Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References

  1. Thorpy MJ, Glovinsky PB. Parasomnias. Psychiatr Clin North Am. Dec 1987;10(4):623-39. [Medline].

  2. Broughton RJ. Sleep disorders: disorders of arousal? Enuresis, somnambulism, and nightmares occur in confusional states of arousal, not in "dreaming sleep". Science. Mar 8 1968;159(819):1070-8. [Medline].

  3. Guilleminault C. Parasomnias. In: Kyger M, Roth T, Dement W, eds. Principles and Practice of Sleep Medicine. 2nd ed. Philadelphia, Pa: WB Saunders;. 1994:567-73.

  4. Rama AN, Zachariah R, Kushida CA. Differentiating Noctural Movements: Leg Movements, Parasomnias, and Seizures. Sleep Med Clin [serial online]. September 2009;4 (issue 3):Available from: MD Consult. Accessed 2/3/10. Available at http://bit.ly/gcrRg1.

  5. Allen RP, La Buda MC, Becker P, et al. Family history study of the restless legs syndrome. Sleep Med. Nov 2002;3 Suppl:S3-7. [Medline].

  6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association;. 2000.

  7. American Sleep Disorders Association. International Classification of Sleep Disorders: Diagnostic and Coding Manual. Rochester, Minn: American Sleep Disorders Association;. 1990.

  8. American Psychiatric Association. Sleep Disorders. American Psychiatric Association DSM5 Development. Available at http://www.dsm5.org/ProposedRevisions/Pages/SleepDisorders.aspx. Accessed 5/5/2010.

  9. Cooper AJ. Treatment of coexistent night-terrors and somnambulism in adults with imipramine and diazepam. J Clin Psychiatry. May 1987;48(5):209-10. [Medline].

  10. Hurwitz TD, Mahowald MW, Schenck CH, et al. A retrospective outcome study and review of hypnosis as treatment of adults with sleepwalking and sleep terror. J Nerv Ment Dis. Apr 1991;179(4):228-33. [Medline].

  11. Schenck CH, Boyd JL, Mahowald MW. A parasomnia overlap disorder involving sleepwalking, sleep terrors, and REM sleep behavior disorder in 33 polysomnographically confirmed cases. Sleep. Nov 1997;20(11):972-81. [Medline].

  12. Schenck CH, Mahowald MW. An analysis of a recent criminal trial involving sexual misconduct with a child, alcohol abuse and a successful sleepwalking defence: arguments supporting two proposed new forensic categories. Med Sci Law. Apr 1998;38(2):147-52. [Medline].

  13. Chiu HF, Wing YK. REM sleep behaviour disorder: an overview. Int J Clin Pract. Oct 1997;51(7):451-4. [Medline].

  14. Olson EJ, Boeve BF, Silber MH. Rapid eye movement sleep behaviour disorder: demographic, clinical and laboratory findings in 93 cases. Brain. Feb 2000;123 (Pt 2):331-9. [Medline].

  15. Allen RP, Picchietti D, Hening WA, et al. Restless legs syndrome: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Med. Mar 2003;4(2):101-19. [Medline].

  16. Allen RP. Race, iron status and restless legs syndrome. Sleep Med. Nov 2002;3(6):467-8. [Medline].

  17. Chesson AL, Wise M, Davila D, et al. Practice parameters for the treatment of restless legs syndrome and periodic limb movement disorder. An American Academy of Sleep Medicine Report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. Nov 1 1999;22(7):961-8. [Medline].

  18. Earley CJ. Clinical practice. Restless legs syndrome. N Engl J Med. May 22 2003;348(21):2103-9. [Medline].

  19. Garcia-Borreguero D, Odin P, Schwarz C. Restless legs syndrome: an overview of the current understanding and management. Acta Neurol Scand. May 2004;109(5):303-17. [Medline].

  20. Zaharna M, Budur K, Noffsinger S. Sexual Behavior during sleep: convenient alibi or parasomnia. Current Psychiatry. Jul 2008;7:21-30. [Full Text].

  21. Ebrahim IO. Somnambulistic sexual behaviour (sexsomnia). J Clin Forensic Med. Mar 23 2006;[Medline].

  22. Shapiro CM, Trajanovic NN, Fedoroff JP. Sexsomnia--a new parasomnia?. Can J Psychiatry. Jun 2003;48(5):311-7. [Medline].

  23. Gluck ME, Geliebter A, Satov T. Night eating syndrome is associated with depression, low self-esteem, reduced daytime hunger, and less weight loss in obese outpatients. Obes Res. Apr 2001;9(4):264-7. [Medline].

  24. Rand CS, Macgregor AM, Stunkard AJ. The night eating syndrome in the general population and among postoperative obesity surgery patients. Int J Eat Disord. Jul 1997;22(1):65-9. [Medline].

  25. Stunkard A, Berkowitz R, Wadden T. Binge eating disorder and the night-eating syndrome. Int J Obes Relat Metab Disord. Jan 1996;20(1):1-6. [Medline].

  26. Howell MJ, Schenck CH, Crow SJ. A review of nighttime eating disorders. Sleep Med Rev. Feb, 2009;13 (1):23-34. [Medline]. [Full Text].

  27. Mahowald MW, Schenck CH. Evolving concepts of human state dissociation. Arch Ital Biol. Apr 2001;139(3):269-300. [Medline].

  28. Gastaut H, Broughton RJ. A clinical and polygraphic study of episodic phenomena during sleep. Biol Psychiatry. 1965;7:197-221.

  29. Leo G. Parasomnias. WMJ. 2003;102(1):32-5. [Medline].

  30. Schenck CH, Bundlie SR, Mahowald MW. Delayed emergence of a parkinsonian disorder in 38% of 29 older men initially diagnosed with idiopathic rapid eye movement sleep behaviour disorder. Neurology. Feb 1996;46(2):388-93. [Medline].

  31. Eisensehr I, Linke R, Tatsch K, et al. Increased muscle activity during rapid eye movement sleep correlates with decrease of striatal presynaptic dopamine transporters. IPT and IBZM SPECT imaging in subclinical and clinically manifest idiopathic REM sleep behavior disorder, Parkinson's diseas. Sleep. Aug 1 2003;26(5):507-12. [Medline].

  32. Stiasny-Kolster K, Trenkwalder C, Fogel W. Restless legs syndrome--new insights into clinical characteristics, pathophysiology, and treatment options. J Neurol. Sep 2004;251 Suppl 6:VI/39-43. [Medline].

  33. Eisensehr I, Ehrenberg BL, Noachtar S. Different sleep characteristics in restless legs syndrome and periodic limb movement disorder. Sleep Med. Mar 2003;4(2):147-52. [Medline].

  34. Pilon M, Montplaisir J, Zadra A. Precipitating factors of somnambulism: impact of sleep deprivation and forced arousals. Neurology. Jun 10 2008;70(24):2284-90. [Medline]. [Full Text].

  35. Silber MH, Richardson JW. Multiple blood donations associated with iron deficiency in patients with restless legs syndrome. Mayo Clin Proc. Jan 2003;78(1):52-4. [Medline].

  36. Wills L, Garcia J. Parasomnias: epidemiology and management. CNS Drugs. 2002;16(12):803-10. [Medline].

  37. Chokroverty S. Editor's corner: restless legs syndrome, a common disease uncommonly diagnosed. Sleep Med. Mar 2003;4(2):91-3. [Medline].

  38. Hening WA, Allen RP, Thanner S, et al. The Johns Hopkins telephone diagnostic interview for the restless legs syndrome: preliminary investigation for validation in a multi-center patient and control population. Sleep Med. Mar 2003;4(2):137-41. [Medline].

  39. Phillips B, Young T, Finn L, et al. Epidemiology of restless legs symptoms in adults. Arch Intern Med. Jul 24 2000;160(14):2137-41. [Medline].

  40. Nichols DA, Allen RP, Grauke JH, et al. Restless legs syndrome symptoms in primary care: a prevalence study. Arch Intern Med. Oct 27 2003;163(19):2323-9. [Medline].

  41. Rodrigues RN, Rodrigues AA, Pratesi R, Krieger J. Outcome of restless legs severity after continuous positive air pressure (CPAP) treatment in patients affected by the association of RLS and obstructive sleep apneas. Sleep Med. Mar 22 2006;[Medline].

  42. Schenck CH, Milner DM, Hurwitz TD, et al. A polysomnographic and clinical report on sleep-related injury in 100 adult patients. Am J Psychiatry. Sep 1989;146(9):1166-73. [Medline].

  43. Plante DT, Winkelman JW. Parasomnias: Psychiatric Considerations. Sleep Med Clin [serial online]. 2008;3:217-219. Available at http://www.sleep.theclinics.com/article/S1556-407X(08)00006-4/abstract.

  44. Mahowald MW. What is causing excessive daytime sleepiness? Evaluation to distinguish sleep deprivation from sleep disorders. Postgrad Med. Mar 2000;107(3):108-10, 115-8, 123. [Medline].

  45. Mahowald MW, Schenck CH. Diagnosis and management of parasomnias. Clin Cornerstone. 2000;2(5):48-57. [Medline].

  46. Fantini ML, Gagnon JF, Filipini D, Montplaisir J. The effects of pramipexole in REM sleep behavior disorder. Neurology. Nov 25 2003;61(10):1418-20. [Medline].

  47. Picchietti D, Winkelman JW. Treatment of depression in patients with restless legs syndrome: What is evidence-based?. Sleep Med. Mar 23 2006;[Medline].

  48. Lesage S, Hening WA. The restless legs syndrome and periodic limb movement disorder: a review of management. Semin Neurol. Sep 2004;24(3):249-59. [Medline].

  49. Kushida CA. Pramipexole for the treatment of restless legs syndrome. Expert Opin Pharmacother. Mar 2006;7(4):441-51. [Medline].

  50. Hening W, Allen R, Earley C, et al. The treatment of restless legs syndrome and periodic limb movement disorder. An American Academy of Sleep Medicine Review. Sleep. Nov 1 1999;22(7):970-99. [Medline].

  51. Thorpy MJ. New paradigms in the treatment of restless legs syndrome. Neurology. Jun 28 2005;64(12 Suppl 3):S28-33. [Medline].

  52. Zaremba PD, Bialek M, Blaszczyk B, et al. Non-epilepsy uses of antiepilepsy drugs. Pharmacol Rep. Jan-Feb 2006;58(1):1-12. [Medline].

 
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Polysomnographic study demonstrates apnea (absence of carbon dioxide fluctuation indicating no flow), chest wall paradox, abrupt increase in tidal volume at end of apnea, and oxygen desaturation. All of these features are consistent with obstructive sleep apnea.
Periodic limb movements on polysomnographic study show intermittent leg electromyographic activity accompanied by electroencephalographic arousals.
 
 
 
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